What are the new guidelines?

Last week saw the announcement of new cholesterol treatment guidelines published by the American Heart Association and the American Cardiology Association. Many believe that the new guidelines will result in millions of additional people being put on statin drugs like Lipitor, Zocor, Crestor, and the many generic equivalents. While this may be true the new guidelines also mean that some people who would previously have been put on statins won't need to.

The main difference between the new guidelines and the old ones is that the new ones put less of an emphasis on the numbers and a greater focus on risk factors that lead to cardiovascular diseases like heart attacks and stroke. Instead of treating everyone with a given cholesterol level the new guidelines recommend treating everyone in certain high risk groups regardless of their cholesterol level.

Its now recommended that everyone who is diabetic be put on statins even if they have normal cholesterol levels. in addition anyone who has a history of heart disease should be on cholesterol meds as well as anyone with a calculated cardiovascular risk of 7.5% or greater. These recommendations will result more people being treated but another recommendation, that patients without diabetes and with normal cardiac risk only be treated if their LDL (bad cholesterol) is more than 190 may mean that some patients currently on statins might be taken off.

Why would someone be put on statins if they have normal cholesterol?

There is a lot more to heart disease than cholesterol levels. More and more evidence points to inflammation as an important factor in causing damage to the walls of our arteries that leads to the formation of plaques and ultimately heart attacks and strokes. As it turns out, in addition to lowering cholesterol levels, statin drugs also have the ability to reduce arterial wall inflammation as well.

When someone has a heart attack or stroke it doesn't happen over night. For decades before the heart attack a slow process was taking place. It all begins with inflammation in the wall of the artery. Arterial wall inflammation can be caused by many things. High blood pressure, diabetes, smoking, and genetic factors can all lead to inflammation. Once inflammation develops it allows LDL cholesterol particles to seep beneath the surface of the artery wall and lodge there promoting a number of steps that ultimately lead to the formation of plaques. Inflammation also makes those plaques more likely to rupture and cause a heart attack ( see "How do heart attacks happen?")

It may turn out that the anti-inflamatory effects of statins are more important than the cholesterol lowering ability of these medications. This is why the current guidelines focus more on conditions that increase the risk of preexisting inflammation then they do on the cholesterol level itself.

Where do we go from here?

If you are a diabetic, have had heart disease or are concerned that you are at risk for heart disease, discuss this with your doctor. If you know your recent cholesterol numbers and blood pressure you can use the calculator below to determine your cardiac risk. If the estimated risk is over 7.5% make your doctor aware and ask him about your options. Finally, if you have no risk factors or you think your risk of cardiac disease is low and you were started on a statin just because your cholesterol was a little high ask your doctor if you still need to take this drug. It may no longer be necessary.